Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Wednesday, July 22, 2009

What are YOU afraid of?

I'll be facilitating a focus group this evening as part of a study I'm involved in concerning the health effects of near-highway pollution. (Info about the CAFEH study can be accessed from the sidebar.) I'm going to start out by asking people, in an entirely open-ended way, what dangers they tend to worry about the most concerning themselves and their families, and then I'm going to present them with some alternative philosophical views about risk and responsibility. This is a subject we touch on here from time to time, and I think it's just fascinating.

As a public health specialist, I happen to have a pretty good idea of the statistical probabilities of death and injury from various causes. I also know that it's not all that simple to think about. There are complications including how old you are likely to be when the particular bad thing happens, the multi-causality of events and the differing regard we have for proximal and distal causes, and the individuality of risk. So it is far from straightforward to say what you should worry about a lot and what you should worry about a little.

Nevertheless, I think I can say that the stuff people are most afraid of is pretty hard to justify as belonging high on the list. For example, al Qaeda could fly airplanes into buildings and kill 3,000 people every year from now till eternity and it would constitute about 1/15 of the number of deaths every year from motor vehicle crashes. DemFromCt's fondest wish could come true and we could have the massive killer flu epidemic he's been cheerleading for and it would kill 1/3 as many people as die from tobacco use every year -- and that would happen once, and be over for all time, whereas the tobacco fatalities would just go on. And so on.

Of course one has to disambiguate these statements. Some people will say that 21% of fatal motor vehicle crashes are "caused" by drunk driving, although that is not a valid conclusion. 21% of drivers in fatal crashes have blood alcohol concentrations above .08% but what we don't know is what percentage of all drivers have BAC > .08%, and it's the difference between those two numbers that is relevant. (BTW, there are more drivers involved in fatal accidents than there are fatalities, since many crashes involve more than 1 vehicle, which makes this even harder to interpret.) In any event, if drunk drivers manage to kill 9,000 people each year, why do they get 20 times the attention of 400,000 tobacco-related deaths each year, and 300,000+ obesity-related deaths?

On the other hand, what is really the "cause" of a tobacco-related death? Is it tobacco marketing and advertising? Hollywood glamorization of smoking? Individual irresponsibility? Peer pressure? Parental inattention? Or should we not even care about tobacco-related deaths because smokers have made a "choice" and we should just respect it? And, whatever we think about these questions, what is the appropriate role of government in protecting people from various kinds of dangers, or encouraging -- or even coercing -- people to engage in less risky behavior?

This is at the heart of a lot of political controversy, so tonight I'll see what some regular white folks think about all this, people who live in a blue collar neighborhood in America's most densely populated city. (I've already done Latinos, and we're doing African Americans next.) I'll let you know what the people have to say.